Patients at risk of coverage denial

Researchers at Brigham and Women’s Hospital analyzed a national sample of Emergency Department visits between 2011-15 to determine what proportion of them could be denied coverage if commercial insurers across the U.S. adopted the policy of a large national insurer, Anthem, Inc., to potentially deny coverage, after the visit, based on ED discharge diagnoses.

Researchers studied visits by a population of over 28,000 commercially insured adults, aged 15-64, and found that the insurer’s list of non-emergent diagnoses would classify coverage denial for 15.7 percent, or 4.6 million ED visits annually. Their findings will be published in the October 19 issue of JAMA Network Open.

“Up to one-sixth of adult emergency department patients with private health insurance would qualify for further review and may be denied coverage under this policy,” said Shih-Chuan (Andrew) Chou, MD, MPH, attending physician in the Department of Emergency Medicine at the Brigham, and lead study author.

Researchers noted that in almost 90 percent of ED visits, the primary presenting symptoms that brought patients to the emergency department were the same presenting symptoms as those with diagnoses at risk of denial. Yet, among these patients, more than 65 percent received emergency-level services, such as imaging or multiple blood tests. Researchers concluded that using a diagnosis-based approach to retrospectively identify inappropriate visits as a means of determining coverage may be problematic because patients make reasonable decisions to go to the ED based on their symptoms.

“Nearly 90 percent of adult ED patients will have symptoms that may potentially lead to a non-emergency diagnosis, and review for possible coverage denial, including symptoms such as chest pain, which is one of the most common reasons patients are hospitalized from the ED,” Chou said.